Clinics in Medical Education

Feedback

Mark Robitaille, MD, Dario Winterton, MD

Published July 7, 2024 | Clinics in Medical Education 

Issue 1 | Volume 1 | July 2024

During the first education workshop, we covered some key concepts and best practices in feedback exchanges.

Feedback vs. Assessment

First, we discussed the difference between feedback and assessment. Feedback ideally occurs on a daily basis, is primarily verbal and, as described above, is designed to discuss current performance and guide future performance. Feedback givers should not be worried about giving “negative” feedback for fear of undermining the learner’s future career, as it is informal, generally verbal, and focused on guiding performance rather than ascribing value or character judgments. Assessments are summative retrospective evaluations designed to formally report to the trainee and education leaders. In our division, the clinical competency committee, program director and associate program directors are responsible for resident assessment.

Key factors in feedback

Feedback is fruitful in the framework of a learning contract, in which the shared goal of all stakeholders (resident, attending, education leadership) is making the trainee the best clinician they can be. A corollary to this contract is the growth mindset – the “implicit belief held by an individual that intelligence and activities are changeable”, and that challenges and failures are opportunities for growth and development.

Feedback must be given in the setting of psychological safety. This encourages interpersonal risk-taking, expression of vulnerability and contribution of perspectives, without the fear of negative consequences.

Finally, it is important to underline that formative feedback is both negative and positive: learners need to have positive reinforcement of good performance and specific feedback for performances requiring improvement.

STAROS model of feedback

We presented the STAROS model of feedback, proposed in a recent NEJM Resident 360 Issue1-2, that involves the following domains.

  • Specific: Trainers need to provide detailed (possibly skill-based) information on what needs improvement and what went well
  • Timely: Feedback should be delivered in small doses and as close to the event as possible to avoid recall bias from either part involved
  • Actionable: Feedback should include guidance on future behavior
  • Realistic expectations: Requirements and expectations should be at the level of the trainee
  • Observable: Feedback should be on directly observed actions
  • Skill-based: Feedback should be given on activities and behaviors, not personality

Barriers to feedback

We discussed some of the most common barriers to feedback exchanges:

  • Giving negative or sensitive feedback is not easy but is vital in the growth of trainees
  • There is often not enough time, or the right occasion, or the right place to give feedback
  • Feedback requires presence and interaction with trainees, both to observe the action and to give the feedback
  • Receivers may not recognize that they are getting feedback, hence this may need to be explicitly stated in some cases
  • The receiver might not be in the previously discussed growth mindset and may thus not receive the feedback as a growing opportunity, but rather as a personal judgement.

Method of feedback exchange

We advocate the ask-tell-ask-add model presented in the same article referenced previously.

  • Ask: open the feedback by asking the receiver to reflect and self-assess their performance. This will help you understand how similar (or different) your assessments are and will help guide the rest of the conversation.
  • Tell: Provide feedback on the observed activity/skill based on the expected level of the trainee (see before)
  • Ask: encourage the trainee to identify steps for improvement and what to change
  • Add: provide further suggestions and plan for follow-up

Conclusion

Feedback is a vital part of education and a key component of our role as trainers and educators. Within the correct framework, feedback is an opportunity for growth to make the resident the best physician they can be. This will be the first of many encounters to aid trainers navigate the intricacies, and beauty, of appropriate feedback and the way this positively impacts training.

REFERENCES

1.  C. Noronha, S. Anathakrishnan – Improving Feedback Exchanges with Residents – Can You Hear Me Now? – https://resident360.nejm.org/expert-consult/improving-
feedback-exchanges-with-residents
2.  C. Noronha, S. Anathakrishnan – How to Receive and Deliver High-Quality Feedback – https://resident360.nejm.org/expert-consult/how-to-receive-and-deliver-high-quality-
feedback